PPH Flashcards
How is PPH defined?
Blood loss >500 ml after NVD / >1000 ml after C/S
What is the difference between primary and secondary PPH?
Primary is within 24 hours of deliverySecondary is from birth until 6/52 post partum
List the risk factors for PPH
Previous PPH. (Previous) C/S. Parity >5. Atonic uterus. Neglect active management of 3rd stage. Assisted deliveries. APH. GPH. Severe anaemia. Age >35. Chronic disease. Multiple pregnancy. Obese.
What causes an atonic uterus?
Shoulder dystocia. Prolonged labour. Macrosomia. Multiple pregnancy. Polyhydramnios. Exhaustion. Over distention. Uterine infection. Chorioamnionitis.
What are the avoidable factors in PPH?
Delay in seeking help. Delay in transport. No attendance. Lack of specific health facilities. Lack of sufficient blood. Inadequate monitoring. Lack of sufficient staff.
What are the 4Ts that can cause PPH and give an example of each.
Tone (atonic uterus)Tissue (RPOC)Trauma (genital tract lacerations)Thrombin (coagulation abnormalities either hereditary or acquired)
What trauma can cause PPH?
Genital tract trauma (lacerations/ tears on the perineum or in the vagina). Inverted uterusRuptured uterus
How do you prevent PPH?
Detect at risk patients. Deliver at appropriate hospital. Detect and rx anaemia antenatally. Active mx 3rd stage. Prevent prolonged labour. Precautions using oxytocin and miso in multips. Avoid inappropriate use of oxytocin. Early latching. Close monitoring for first 2 hours after birth.
How to manage PPH?
Call for help. Active management of 3rd stage. Resus. Diagnoses cause of bleeding (4Ts). Control bleeding. Try latch baby. Treat. IV lines. Blood samples. Catheterised and monitor output. Rub up uterus/ bi annual compression. 20u oxytocin in 1l ringers. Give O2.
What is done if the placenta is incomplete?
Evacuate the uterus
What do you do if the placenta has not delivered?
Repeat CCT and manual removal
What do you do if the placenta is completely removed but the uterus remains soft?
Massage and expel clots. Continue oxytocin infusion. IV ergometrine 0.5 mg or repeat 1 amp oxytocin IMI. Miso 400-600 ug PR. PGF2a 5 mg in 10ml saline - 1 ml injected into myometrium. Balloon tamponade.
What is done if the bleeding is ongoing?
Examine the patient in theatre. Explore for RPOC. Laparotomy for B-lynch suture or other uterine compression sutures. If that fails, hysterectomy.
What is the management plan if the uterus is firm but bleeding continues?
Suture lacerations of the perineum, vagina and cervix.
What is done if the uterus is not felt?
Check vagina for inverted uterus, and replace immediately. (Johnson maneuver)Hydrostatic reduction- infuse warm saline into vagina (O’Sullivans technique)
